type - 2 diabetes mellitus:indian and global scene …pubmedinfo.com/pdf/type2 diabetes.pdf · type...

Type - 2 Diabetes Mellitus:Indian and Global Scene –

Burden & Challenges.

Head of Diabetes Department,Voluntary Health Services,

Chennai, Tamil Nadu, India.

Dr.C.V.Krishnaswami – FRCP(E).,F.A.M.S.D.T.M & H(EDIN)

Diabetes meets Medical Informatics

Diabetes mellitus is a common household disorder, which is a

life long companion, genetically inherited, manifests at any age

from childhood to senescence and if neglected causes serious

complications of vital systems in the body. The magnitude of this

problem at present and in future, and how best to cope with it,

at the level of the individual, community, and the nation and the

roles each can play towards the dissemination of awareness and

the information to enable early detection, management,

mitigation of complications, and planning strategies to prevent

the condition are outlined. The important value of medical

informatics in the management as well as prevention of diabetes

has to be understood by all concerned if any program has to be

successfully implemented in the containment of this ubiquitous

disorder.

Year Population of India

(in millions)

Prevalence

(in millions)

Percentage

(%)

2002 1000 + 30 3.0

2025 1250 + 57 4.5

(WHO Projections – 1999)

Prevalence of Type – 2 Diabetes Mellitus in India

Type 2 Diabetes (NIDDM or Non-Insulin Dependent Diabetes

Mellitus)

Indian and Global Scene : Burdens and Challenges

Diabetes Mellitus is the commonest Medical Problem of the 21st

Century, affecting the quality of day to day life of over 150

million people of the world cutting across age, gender, racial and

economic barriers.

Prevalence of NIDDM in the age range 30 – 64 Years in

Selected Populations

WHO Technical Report Series, 1994

PV Asha Bai*, CV Krishnaswami**, M Chellamariappan***

RESULTS:

A total of 1198 persons, 455 (38%) females and 743 (62%) males,

participated in the study. While 116 (9.7%), suffering from Diabetics

were exempted from remaining 1082 (90.3%) , 663 (61.3%) males and

490 (38.7%) females, were screened by OGTT.

Department of Diabetes, The VHS Medical Center, TTTI Post,

Chennai –600113.

JAPI 1999, VOL 47, NO 11

Prevalence and Incidence of Type - 2 Diabetes and Impaired

Glucose Tolerance in a Selected Indian Urban Population

Place of Survey Year Prevalence of

Diabetes

Urban Rural

ICMAR, INDIA2 1972 2.3% 1.5%

Multicentre2 1979 3.0% 1.3%

Daryagunj, New Delhi2 1986 9.0%

Kudremukh, India2 1988 5.0%

Eluru3 1989 6.1%

Chennai4 1992 8.2% 2.4%

Kerela5 1999 16.3%

Kashmir6 2000 6.14%

C S Yagnik, NFI Bulletin, July 1995

Rao PV at al, Diabetes Res Clin Pract 1998 Jun 20; 7(1): 29-31

Ramachandran a eet al, Diabetologia 1992 Feb; 40(2): 232-7

Raman Kutty V et al, Ethn Health 1999 Nov; 4(4): 231-9

Zargar AH et al, Diabetes Res Clin Pract 2000 Feb; 47(2): 135-46

Eligible subjects

For OGTT(75g) 663 419

1082 (61.3%) (38.7%)

(90.3%)

1198 743 455

Volunteers (62%) (32%)

Numbers Male(%) Female(%)

The I.I.T Study - Population

known DM 80 36

116(9.7%) (69%) (31%)

PP.1060 JAPI,1999 ,Vol. 47, No .11

Sex(N) Normal(%) IGT(%) DM(%)

Male 450(67.9) 155(23.4) 58(8.7)

N663

Female 275(65.6) 120(28.6) 24(5.7)

N419

Total 1082 725 275 82

The I.I.T Study - Population

PP.1060 JAPI,1999 ,Vol. 47, No .11

Out of 1000 persons without diabetes, 444(63.8%) with normal GTT

and 252(36.2%) with IGT, participated in repeat screening

in 1993.

1 normal person(0.7%)

14 with IGT (5.5%)

The I.I.T Study - Results of OGTT – II (Follow - up) -1993

PP.1060 JAPI,1999 ,Vol. 47, No .11

Diabetes Mellitus in 1 year

Conclusions:

1. 64.3% of those with IGT Reverted to normal

2. 30.2% remained status Quo.

3. 5.5% of IGT Diabetes Mellitus

4. The annul incidence Type - 2 Diabetes Mellitus for

both sexes was 2.2%

The I.I.T Study - 1992 - 1993

PP.1060 JAPI,1999 ,Vol. 47, No .11

THE LANCET

EDITORIAL

Do epidemiologists cause epidemics?

VOL 341: April 17 1993

BMJ

The Scandal of Poor Medical Research

We need less research, better research, and research done for

the right reasons .

London Saturday, January 1994

Original article

Prevalence of Known Diabetics in Chennai City

PV Asha Bai*, BN Murthy+, M Chellamariappan**, MD Gupte++,

CV Krishnaswami***

Abstract :

Aim: To determine prevalence of known diabetes in those

more than 20 years of age in Chennai city.

JAPI, Vol.49, October 2001

Prevalence of Known

Diabetes in Chennai


Urban population was selected for the survey assuming that

prevalence of known diabetics as 5.0% in those aged > 20

years, the cluster sample size calculated to estimate it with

95% CI and +/- 10% precision, was 25,800 individuals of all

ages. Special workers survived this population obtained from

200 households in each of 30 randomly selected corporation

divisions of the city, by house-to-house enquiry. General

information and life status of every member of the household

were recorded on prescribed forms. This survey was

conducted during January - July, 1998.

Prevalence of Known Diabetes in Chennai

Methodology :


Among 26,066 individuals of all ages 779 had known diabetes and

99.4% of them had Type - 2 diabetes. The prevalence of known

diabetes was 2.9% for all ages and both sexes combined. Crude

and age-standardized prevalence was 4.9% (95% CI 4.6 - 5.2) for

those aged > 20 years. The standardized prevalence was 10.5% (95%

CI 9.8 - 11.2) in those aged > = 40 years. The prevalence was

significantly high ( p < 0.05 ) in females.


Results :


The prevalence of known diabetes was low in total population but

increased in those aged > 20 and further increased in those aged >=

40 years. The causes for high prevalence in > 40 years age group

needs to be explored in this population.

( J Assoc Physician India 2001; 49 : 974 - 981 ).



Conclusion :

Sl-no Div-No Name of Division

1 1 Kodungaiyur (West)

2 5 Jeeva nagar (North)

3 10 Kumarasamy Nagar (South)

4 16 Grace Garden

5 23 Kondithope

6 29 Seven Wells (South)

7 34 Perambur (North)

8 39 Wadia Nagar

9 44 Perumal Koil Garden

10 50 Agram (North)

11 55 Viduthalai Gurusamy Nagar (South)

12 60 Maramalai Adigal Nagar (South)

13 63 Villiwakkam (North)

14 66 Anna Nagar

15 70 Kilpauk (North)



Sl-no Div-No Name of Division

16 75 Aminijikarai (West)

17 80 Nehru nagar

18 88 Umarapular nagar

19 95 Azath nagar (South)

20 103 Dr.Ambedkar Nagar

21 109 Thousand Lights

22 115 Alwarpet(North)

23 120 Navalar neducheziyan Nagar (East)

24 125 Kamarajar Naga r(South)

25 130 Kodambakkam

26 134 Kumaran Nagar

27 138 G.T.Naidu Nagar (East)

28 142 Beemannapet

29 148 Avvai Nagar (North)

30 153 Velachery

Prevalence of Known Diabetes in ChennaiJAPI, Vol.49, October 2001

AGE - SPECIFIC PREVELANCE OF KNOWN DIABETES ACCORDING TO SEX

AGE MALES FEMALES TOTAL

(YRS) PEOPLE DIABETES PREVELANCE PEOPLE DIABETES PREVELANCE PEOPLE DIABETES PREVELANCE

0-9 2066 0 0 2000 0 0 4066 0 0

10-14 1267 0 0 1224 1 0.08 2491 1 0.04

15-19 1374 0 0 1356 0 0 2730 0 0

20-24 1353 0 0 1441 5 0.3 2794 5 0.2

25-29 1350 5 0.4 1461 4 0.3 2811 9 0.3

30-34 1168 7 0.6 1046 11 1.1 2214 18 0.8

35-39 1094 23 2.1 1068 24 2.2 2162 47 2.2

40-44 908 42 4.6 758 42 5.5 1666 84 5.0

45-49 818 56 6.8 675 51 7.6 1493 107 7.2

50-54 604 72 11.9 499 65 13.0 1103 137 12.4

55-59 425 61 14.4 354 52 14.7 779 113 14.1

60-64 389 46 11.8 340 59 17.4 729 105 14.4

65-69 223 34 15.2 191 39 20.4 414 73 17.8

70+ 327 38 11.6 287 42 14.6 614 80 13.0

TOTAL 13366 384 2.9 12700 395 3.1 26066 779 3.0



So, our data indicates that Type - 2 Diabetes clinically affects people

largely between the ages of 40 -70 years - at the prime time in their

lives - and producing complications after 15 to 25 years which

necessitate complex and expensive treatment when they are at a

low ebb both physically and economically.



The Natural History of Non-Insulin-Dependent Diabetes

Mellitus

The windows of opportunity in the prevention of Diabetes

Mellitus & its consequences

The Natural History of Diabetes Mellitus

Types of Diabetes Mellitus Seen in Young People ( < 40 years of

age )

1. Type - 1 Diabetes Mellitus (IDDM / JIDDM ( < 15 Years ) 80%

2. Mody ( With its Various - Genetic Subtypes ) 3 - 5%

3. FCPD ( Peculiar to Para equatorial regions (15 – 30 Yrs )

Now classified by WHO as sec Diabetes Mellitus ) 2%

4. E.O.D/NIDDY 25 <40 Yrs

( Early Onset Type - 2 Diabetes Mellitus ) 10%

5. LADA (IDDM Onset > 25 Years ) 1- 2%

6. Genetic Syndromes Assoc with Diabetes Mellitus sec to

Pit Tumor etc. 0.5%

7. Type - 2 Diabetes Mellitus in Childhood 0.5%

• Diabetes in Young People.

- MODY (5 Genetic Sub Types described).

- EOD (Type – 2).

- Type - 2 Diabetes Mellitus in Children.

- +/- LADA (Type – 1).

- FCPD (Fibro Calculus Pancreatic Diabetes – Now

classified by the WHO as a secondary form of

Diabetes)

Types of Diabetes Mellitus Seen in Young People

( < 40 years of age )

•Type - 2 Diabetes Mellitus in very young children is being

increasingly reported from Japan, Singapore, & Hong Kong:

• In Japan Type - 2 Diabetes Mellitus in 6-12 Years age

Groups.

in 1976 0.2/100,000/Yrs

1999 2.0/100,000/ Yrs

• In 12 – 15 Years age Group:

• 1976: L 7.3/100,000/Yrs

1995: 13.5/100,000/Yrs

• This in crease is correlated with affluence and increased

reported intake of animal protein & Fat (Fall, CHD, Barker

DJP(1997) Indian Pediatr)



The bottom line of Type-2 Diabetes Mellitus is that we are

born with the gene-complex and manifest it somewhere

down the life span.

Type-2 Diabetes Mellitus of childhood ( < 15 Years)

MODY ( < 25 Years )

EOD / NIDDY ( 25 - 40 Years )

NIDDM ( > 40 Years)

Why not LOD / NIDDE ?

The fact is Type - 2 Diabetes Mellitus is our companion from

birth and is called a „Disorder‟. When it manifests Biochemically

or clinically and a „Disease‟ when it gives raise to complications.

Hence any attempt at the research on its prevention is surely

best attempted at an early stage.



How early?

„The child is the father of the man‟

- Samuel Johnson

1. To identify the real number of those in this age-group

diabetes as those running the risk of having it.

Three Reasons to focus our Attention on „Diabetes in young

people‟(below 40 yrs)

2. Early detection:

Thus prevent / reduce Type - 2 Diabetes Mellitus Numbers

which are reported increasing/ (in the >40 yrs) in our

population / world.

Try & Modify factors to arrest the progression; Attempt at

reversal or regression of IGT stage.



Education

3.„Back to the future‟

J.C.Cherve

Molecular genetic research into diabetes in young people could

prove to be most useful in discovering the preventive strategies

for NIDDM-and this has to be done EARLY IN LIFE - How Early?



(IDF –Helsinki)

Early Diabetes in Early life

Rafael A.Camerinin-Davalos , Harold S.Cole

Can the art of predictive medicine anticipate the development of

diabetes? If it is so, how early in life is the disease trend manifest?

How early is early enough to attempt to delay the progression of, or

perhaps even prevent the abnormalities? New approach and

techniques are currently being developed which have important

implications to the understanding of the sequence of events leadings

to the disease itself.

• From the manifestations of the disease, we are now looking

at the molecular changes responsible for it. It has become

apparent that the search should start at the very beginning

of life, if possible, at conception. Will that suffice?

Academic Press Inc., New York San Francisco London 1975

Early Diabetes in Early life

Should we have mass diabetes detection camps?

2. Strategies to contain and convert (revert) IGT‟s ?

3. Should long term Drug interventions be considered as prophylaxis or

preventive measures? ( Ethics , morality, wisdom? )

4. Are life-style modification measures useful, pragmatic, and

Sustainable?

5. Diet and Nutrition:

What role? How and whom to educate (Educating the literate)?

How to combine ancient wisdom with modern technologies and bridge

the Generation next gap?

6. How to combine the science and art of exercise?

-of yoga, and allied self-control disciplines.

7. How to cope with Exotic therapies and Ad blitz?

Acupuncture!

Acupressure!

Magnetotheraphy!

Ceramic current therapy!

Herbal concoctions and capsules!

Type - 2 Diabetes Mellitus

Challenges:

1.

Diet, Exercise reduce diabetes risk : Study

The US government‟s National Institutes of Health (NIH) on

Wednesday announced the results of a diverse group of 3,234

overweight Americans with impaired glucose tolerance, a

condition that often precedes diabetes.

Participants who were directed to eat a low-fat diet and to

engage in moderate exercise, such as brisk walking or riding a

bike for 30 minutes a day five days a week, reduced by 58 percent

their risk of getting type 2 diabetes, which accounts for up to 95

percent of all cases of the incurable diabetes.

Glucophage, approved in 1995 to treat type 2 diabetes, is a pill

that lowers blood sugar. The company said it was considering

asking the government to approve the drug for preventing

diabetes as well as treating it.

.

The study was designed to last four years, but Mr. Spiegel said

the striking nature of the results led researchers to end a year

early to get the word out about diet and exercise.

“While the lifestyle intervention was effective across all age

groups, all minority groups and both genders, that was not the

case with metformin,” Dr Allen Spiegel , director of the NIH‟s

National Institute of Diabetes and Digestive and Kidney Diseases,

which backed the study, said in an interview.

The study found Glucophage was effective primarily in the most

obese patients and those in the youngest age group studied, ages

25 to 44. A low-fat diet and exercise however produced strong

results across the broad.

Diet, Exercise reduce diabetes risk : Study

Type-2 diabetes – Short Term Approaches

1. Heightening awareness in a positive way.

2. Life style modifications : Practical models under varied

„patient‟

situations.

3. Treatment & surveillance for Stage II and III (clinical diabetes

& complications respectively) with effective therapeutic

interventions.

4. Identification and avoidance of Iatrogenic (drug-induced)

Complications.

5. Strategies for containment of serious complications like

retinopathy (eyes) , Nephropathy (kidneys), Renal failure,

Diabetic Foot etc., so as to avoid expensive treatment

modalities like eye surgery, dialysis & Kidney Transplant,

amputation of limbs etc.

1. Look after young and adolescent persons particularly women,

with balanced nutrition and nutrients

2. Pregnancy Care Programme: It is now well established that

under weight babies at delivery, have higher risk of developing

diabetes, hypertension and coronary artery disease later in

life. Research is required amongst Indian subjects on the

positive impact of nutrients like Folic Acid, Magnesium, Vit B6

and Vit E and metabolism of pregnant women and to get

optimal birth weight for the babies.

3. Inclusion of appropriate physical exercise in the school

curriculum from primary school onwards, is of utmost

importance.

4. Establishment of Community Fitness Centers – should be

popularized, affordable (if necessary subsidized and

maintained consistently well).

Type-2 diabetes – Long Term Approaches

Continued…

5. Installation of „Touch screen Diabetes Information Help-line

Centers‟ in schools, colleges, workplaces, hospitals etc. These

centers could act as Multipurpose Information & Help-line

Kiosks‟ for all important health problems like Diabetes, Heart

ailments, Hypertension, TB Bronchitis & Asthma etc.

These „Kiosks‟ could be planned as Revenue earning sponsored

projects.

6. A Centre/State co-ordination Committee may be formed to

monitor the implementation and progress of the National Tele

Health Plan.

7. Government centered projects to produce drugs and aids for

diabetes management on subsidised cost for treatment of

Juvenile Insulin Dependant Diabetes Mellitus cost.

8. Maintenance of National Epidemiology register for both Type 1

and Type 2 diabetes using Electronic On Line Medical Record

System with updating of data and information analysis every 5

years.

Type-2 diabetes – Long Term Approaches

Prevention of Type – 2 diabetes

Prof. Sir. George Alberti (IDF President and immediate Past

President of the Royal College Of Physicians, London) states that

“We shall not be successful until governments and their agencies

take the problem seriously. It is largely Socio-Political rather than

medical.

Diabetes voice Dec 2001, Vol 47, issue 4 P5

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